=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063891992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUCHITA ERVIN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2015
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 W BROADWAY STE 104
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-405-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1955 W BROADWAY STE 104
-----------------------------------------------------
City | MONONA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53713-3700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-405-3002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 17263-130
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 440-228
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6487-125
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------